Effect of dynamic

orthoses on gait: a
retrospective control
study in children with
hemiplegia
Leen Van Gestel*PT MSc, Department of Rehabilitation
Sciences, Faculty of Kinesiology and Rehabilitation Sciences;
Guy Molenaers MD PhD, Department of Musculoskeletal
Sciences, Faculty of Medicine, Katholieke Universiteit Leuven;
Catherine Huenaerts PT MSc, Clinical Motion Analysis
Laboratory, CERM, University Hospital Leuven;
Jos Seyler CPO, Centre of Technical Orthopaedics,
University Hospital Pellenberg;
Kaat Desloovere PhD, Department of Rehabilitation
Sciences, Faculty of Kinesiology and Rehabilitation Sciences,
Katholieke Universiteit Leuven, Belgium.
*Correspondence to first author at Faculty of Kinesiology
and Rehabilitation Sciences, Department of Rehabilitation
Sciences, Tervuursevest 101, 3001 Heverlee, Belgium.
E-mail: leen.vangestel@faber.kuleuven.be
DOI: 10.1111/j.1469-8749.2007.02014.x
Several positive influences of orthoses on gait in children with
cerebral palsy have been documented, as well as some
detrimental effects. Most importantly, push-off is decreased in
orthoses, compromising a physiological third ankle rocker.
The aim of this study was to evaluate the effect of three types
of orthosis on gait in a homogeneous group of children. All
orthoses aimed at improving push-off and normalizing the
pathological plantarflexionknee extension couple. Thirty-
seven children (22 females, 15 males) with hemiplegia, aged 4
to 10 years (30 Gross Motor Function Classification System
[GMFCS] Level I, six GMFCS Level II), walked barefoot and
with orthoses being either Orteams

(orthoses with the dorsal

part containing 11 sleeves), posterior leafsprings (PLS), or
Dual Carbon Fibre Spring ankle foot orthosis (AFOs

; CFO:
carbon fibre at the dorsal part of the orthosis). All orthoses
were expected to prevent plantarflexion and allow dorsiflexion,
thus improving first, second, and third rocker. The orthoses
were compared through objective gait analysis, including 3D
kinematics and kinetics. All orthoses successfully improved
the gait pattern and only small differences were noted between
the configurations of the different orthoses. The CFO

,
however, allowed a more physiological third ankle rocker
compared with the Orteam

/PLS. Although the PLS ensured

the highest correction at the ankle around initial contact, the
CFO

created a significantly higher maximal hip flexion

moment in stance. In general, the results of this study
indicated a substantial functional flexibility of the CFO

.
Conservative treatment of children with cerebral palsy (CP)
includes the fitting and application of orthoses. In children
with hemiplegia, orthoses have been prescribed to correct
the ankle position and to influence the pathological plan-
tarflexion knee extension couple with knee hyperexten-
sion. For the past couple of decades, the solid ankle foot
orthosis (SAFO), hinged AFO (HAFO), dynamic AFO (DAFO),
posterior leafspring (PLS), and Orteam

have been applied

most frequently to achieve these goals. All these orthoses,
except for the SAFO, combine a built-in plantarflexion stop
with free dorsiflexion (allowed range of movement [ROM]
depending on the type of orthosis).
In recent literature, multiple advantages of orthoses have
been reported. In normal gait, ankle motion is characterized
by three rockers. During the first rocker, after initial contact,
the ankle plantarflexes until the foot is flat on the floor. The
ankle then begins to dorsiflex, resulting in a rotation of the
tibia over the stationary foot (second rocker). The third rock-
er, or push-off, represents heel-lift at terminal stance. Both
the first and the second ankle rocker improved through the
use of orthoses.
17
Moreover, in a study by Buckon et al.,
both the HAFO and the PLS decreased knee hyperextension
by preventing ankle plantarflexion.
1
The hinged joint, how-
ever, made the HAFO bulky, costly, and clumsy, thereby
leaving the PLS as the best treatment option.
8
Unfortunately, several studies also indicated that walking
with an orthosis impairs the third ankle rocker. Push-off was
found to decrease when children walked with HAFO, SAFO,
DAFO, or PLS (compared with barefoot or shoes walk-
ing).
3,4,6
For the past few years, however, extensive research
has tried to prove a spring-like assist of the PLS to push-off.
This improvement of the third rocker was anticipated
through an energy return after deflexion of the orthosis in
the first and the second rocker. So far, though, no such influ-
ence has been demonstrated.
1,6
Although the Orteam

has
been reported as improving push-off as well, there are few
studies about the effect of Orteams

on gait.
When reviewing recent literature, several general short-
comings emerge. First, there are few comparative studies of
different types of orthoses, which are indicated for a homo-
geneous group, thereby aiming at the same treatment
goals.
1,35,911
Second, the set of objective data used for fur-
ther analysis is often too limited, enabling only a restricted
evaluation of AFOs.
1,36,912
Third, studies often lack appro-
priate control groups and/or control conditions, compro-
mising the correct interpretation of observed influences of
AFOs on gait. There should be at least one alternative ortho-
sis with the same goal setting included in the study, in order
to weigh and compare the first orthosis with a similar
one.
3,6,9,10,12
Finally, when reading (recent) literature, the
researcher is often confronted with contradictions in report-
ed effects of certain AFOs on gait.
1,3,13,14
The aim of this study was to evaluate the effect of three
orthoses with similar goal settings on gait in a homogeneous
group of children with hemiplegia presenting with a patho-
logical plantarflexionknee extension couple. For this pur-
pose, the PLS was compared with the Orteam

and a new
AFO called Dual Carbon Fibre Spring AFO

(CFO). All three

orthoses were characterized by a dynamic, flexible configu-
ration and were tuned to: (1) prevent plantarflexion, thus
improving clearance in swing and first ankle rocker; (2)
allow dorsiflexion, thus improving second ankle rocker; and
Developmental Medicine & Child Neurology 2008, 50: 6367 63
(3) absorb energy in second ankle rocker returning it in third
ankle rocker, thus increasing push-off. In addition, these
orthoses were tuned to normalize the pathological plan-
tarflexion knee extension couple and had to enable a maxi-
mal correction at the knee and hip.
Method
PARTICIPANTS
For this (retrospective) study, children with hemiplegia were
selected from the database of the Pellenberg Clinical Motion
Analysis Laboratory, Belgium. The inclusion criteria for
enrolment were: (1) diagnosis of hemiplegia (excluding
asymmetric diplegia, associated athetosis and/or ataxia); (2)
age between 3 and 15 years; (3) no treatment with botu-
linum toxin-A (BTX-A) in the 6 months before the evaluation;
(4) no previous multilevel surgery; (5) medium to good coop-
eration of the child; (6) available data for at least one gait
analysis, with and without orthosis and additional clinical
examination; and (7) use of Orteams

, Leafsprings, or CFOs

for at least 50% of the day.

The mean age was 8 years 5 months (SD 2y 8mo; range
414y); 14 children had left- and 22 had right-body side
involvement. There were 22 females and 15 males; 30 were
classified as Gross Motor Function Classification System
Level I, six as GMFCS Level II.
All children were classified according to type of orthosis,
resulting in three groups of children wearing either Orteams

,
Leafsprings, or CFOs

. These children were then mutually

matched across groups according to two criteria. The first
matching criterion was based on Gages classification of hemi-
plegic gait; three groups of different joint-level involvement
were thus created: A1A2, K1K2, and H1H2.
15,16
The second
matching criterion was the age at the time of gait evaluation.
The age of children with CP is crucial as the natural maturation
of gait with increasing age, combined with the progressive
nature of CP, leads to a continually changing clinical presenta-
tion. The (three) final groups consisted of 12 children (n=36)
who met all the inclusion- and matching criteria.
All orthoses were individually selected, adapted, and opti-
mally tuned (shank neutral to maximum 10 anteriorly
inclined, flexible foot roll-over to ensure normal third rocker)
by the multidisciplinary team of the Pellenberg Clinical
Motion Analysis Laboratory, based on clinical examination and
objective evaluation through gait analysis. The gait pattern
observed in the gait analysis determined the amount of flexi-
bility allowed in the orthosis and the direction of tuning of the
orthosis.
Participants were informed of the nature of the study and
they, or their guardian, gave their informed consent.
The study was approved by the medical and ethical com-
mittee of the Katholieke Universiteit Leuven.
ORTHOSES
Flexible posterior leafsprings were used, which extended
proximally to the calf to just below the neck of the fibula and
distally had a footplate that extended the length of the plantar
surface of the foot to the tips of the toes. They were secured
with an upper strap across the anterior proximal tibia and
trimmed posterior to the ankle malleoli, creating sufficient
flexibility towards dorsiflexion.
6
Their goal was to pre-position
the foot for heel initial contact, allow dorsiflexion during the
second ankle rocker, correct the pathological plantarflexion-
knee extension couple, promote push-off, and achieve foot
clearance in swing. Furthermore, the flexible forefoot part
ensured a normal foot roll-over (Fig. 1).
Orteams

aimed to achieve the same goal using a different

orthosis configuration. The dorsal part of the Orteam

con-
tained five major and six minor sleeves. These sleeves allowed
additional mobility for dorsiflexion, whereas plantarflexion
was limited (Fig. 1).
The CFO

configuration resembled the PLS, except for the

dorsal part which was cut into two. A carbon L -shaped plate
consisting of two carbon springs (Ossur

paediatric spring),
spanned the gap. The Ossur

paediatric spring was made from

64 Developmental Medicine & Child Neurology 2008, 50: 6367
Table I: Significant p values for differences in effects of orthoses on the gait parameters through a Friedman and post-hoc
Wilcoxon signed-rank test along with the corresponding difference scores between barefoot and orthosis gait within each group
Parameter description Friedman Group 123 Group 12 Group 23 Group 13
Group 1 Group 2 Group 3
(Orteam) (PLS) (CFO) p p p p
Ankle
Angle at initial contact () 10.4 11.2 5.3 0.0168 0.8139 0.0096 0.0995
Hip
Maximal flexion moment in stance (Nm/kg) 0.06 0.20 0.29 0.0278 0.0342 0.4802 0.0047
PLS, Posterior Leafspring; CFO, Dual Carbon Fibre Spring AFO

; p, Bonferroni corrected p values.

Figure 1: LR; posterior leafspring (PLS), Dual Carbon Fibre
Spring AFO (CFO)

, and Orteams

.
a combination of carbon and kevlar fibres pre-impregnated
with epoxy resin. The design of the spring allowed for good
durability, stiffness to weight ratio, energy return characteris-
tics, and consistent performance. Different types of carbon
material were available for the springs: type 1 through 3 dis-
played progressively more resistance to bending forces. The
applied carbon springs in this study were all type 1 (Fig. 1).
STUDY DESIGN
Patients initially walked barefoot after which their own shoes
were combined with their orthoses. All orthoses were applied
bilaterally. Bilateral use of AFOs is a generally accepted treat-
ment strategy at our hospital and is believed to promote sym-
metry in children with hemiplegia.
Before gait analysis, lower limb dimensions, body height,
and weight were registered to enable an estimation of joint
centre locations and segmental inertia parameters. Bimalleolar
distance was re-measured for each walking condition. Patients
walked on a 10m walkway at a self-selected speed. Kinematic
measurements were collected using an eight-camera VICON
system (612 data capturing system measuring at 120Hz, with
lower limb PlugInGait marker set, VICON, Oxford Metrics,
Oxford, UK). Three force plates (Advanced Mechanical
Technology Inc., Watertown, MA, USA) were embedded in
the walkway for force registration. Surface electromyogra-
phy (EMG) data were collected on eight lower extremity
muscle groups, using a 16 channel K-Lab EMG system
(Biometrics, the Netherlands). Workstation and Polygon
software (Oxford Metrics) were used to define the gait cycles,
to determine the spatio-temporal parameters, and to esti-
mate the joint angles and internal moments and powers
(normalized for body mass). Only the kinematic and kinetic
data of three trials of the involved side were used for further
analysis in this study.
After walking barefoot, three foot markers had to be
removed from the foot to be replaced on the shoes. Members
of the multidisciplinary team rigorously controlled the strict
replacement of the foot markers.
STATISTICAL ANALYSIS
An age-related subgroup of the healthy database of the
Pellenberg Clinical Motion Analysis Laboratory (n=51, age
range 311y) who underwent a single gait analysis in the
same laboratory according to the same standardized proto-
col was used throughout this paper as reference data.
To evaluate the overall effect of flexible orthoses on gait in
children with hemiplegia, all orthoses data (irrespectively of
type of orthosis) were combined in one orthoses group
(n=36) whereas all the barefoot data were merged in one
barefoot group (n=36). The mean and standard deviation
(SD) were calculated for each gait parameter in both groups.
Barefoot and orthoses data were then compared through a
paired t-test, determining the effect of flexible AFOs (in gen-
eral) on gait.
The total group was then subdivided into the three differ-
ent orthosis groups of 12 children (wearing either Orteams

,
PLSs, or CFOs

). For each group and each condition (bare-

foot or AFO) the median and interquartile range (IQR) were
calculated for each gait parameter registered in the gait
analysis. Within each group, a Wilcoxon signed-rank test was
performed to determine statistically significant effects of the
AFOs. Furthermore, a Friedman test, and post-hoc Wilcoxon
signed-rank test were performed across the three groups,
looking for any statistically significant difference in the effect
on gait of the three orthoses (difference scores).
A Bonferonni correction per group of parameters (kine-
matics and kinetics) and per level (ankle, knee, hip, pelvis)
was applied to reduce the likelihood of false-positive results,
leading to a level of significance of p<0.010. Reported signif-
icant differences/findings in this paper will always refer to
statistically significant findings.
All statistical procedures were performed with the SAS system
(SAS Institute Inc, SAS Campus, Dr Cary, NC 27513, USA).
Results
The main focus of this paper is on the effect of the individual
orthoses. The general impact of orthoses on gait will be dis-
cussed briefly.
An overview of the mean and SD for all the gait parameters
of the general barefoot and orthoses group can be found in
Table SI (supplementary material, published online). In the
same table, the results of the paired t-test can be found along
with the normal data.
In general, cadence significantly decreased while step
length and walking velocity significantly increased in orthoses
(all p=0.001). Apart from mean foot progression in stance and
plantarflexion moment in mid-stance, all ankle parameters
were significantly influenced by the use of AFOs (p=0.001-
0.006). Knee range of motion during shock absorption,
swing kinematics, and most knee kinetics also significantly
changed (p=0.0010.004). About half of the hip kinematics
experienced a significant influence from orthoses while all hip
moment and power graphs were significantly increased
(p=0.0010.006), except for maximal abduction moment in
stance and maximal power generation at pre-swing. Only lim-
ited changes at the pelvis were observed, as only mean pelvic
tilt significantly increased (p=0.006).
In general, the above described results were confirmed
through the Wilcoxon signed-rank test in each separate ortho-
sis group. Although similar influences of orthoses were
observed, several no longer reached significance because of
the smaller sample sizes of the three separate orthosis groups.
An overview of the median and IQR for all the gait parameters
of the different walking conditions and the p values for the
Wilcoxon signed-rank test can be found in Table SII (supple-
mentary material, published online). Only unexpected or
remarkably different influences of the three orthoses on gait
will be reported in the following paragraphs.
Ankle dorsiflexion in stance and power absorption at load-
ing response varied substantially over the different assessment
conditions, but only the CFO

could significantly improve

ankle dorsiflexion at loading response compared with a bare-
foot condition (p=0.007). The Orteam

and the PLS increased

(but on average overcorrected) maximal ankle dorsiflexion in
stance (significant for the Orteam

, p=0.001).
Clinically worthwhile is that data of gait analysis indicated
that both the Orteam

and the PLS improved (decreased) maxi-

mal knee extension in stance, whereas the CFO

created knee
hyper-extension (respectively p=0.970, p=0.204, p=0.266). At
the hip, on the other hand, both the PLS and the CFO

increased maximal extension in stance, whereas the Orteam

decreased it (respectively p=0.622, p=0.027, p=0.301).

Finally, a separate Friedman analysis with a post-hoc
Wilcoxon signed-rank test compared the effects of the three
Effect of Dynamic Orthoses on Hemiplegic Gait Leen Van Gestel et al. 65
different orthoses configurations on walking (Table I). A sig-
nificant difference could be noted for two parameters. First
of all, the PLS provided a greater correction at the ankle (sig-
nificant compared with the CFO

), creating an almost physi-

ological angle at initial contact. Second, the CFO

created a
significantly higher maximal hip flexion moment in stance,
compared with the Orteam

.
Discussion
TIME AND DISTANCE PARAMETERS
In all orthoses a decreased cadence and increased step
length resulted in an improved walking velocity, supporting
the findings of previous studies.
1,5,10
Timing of toe-off tend-
ed to occur later in the gait cycle indicating a greater stability
in stance (Table SI).
ANKLE PARAMETERS
As expected, all three orthoses improved the first ankle rock-
er as they enabled the children to achieve a heel initial con-
tact.
1,36,8
The PLS was the only orthosis that actually
normalized the first ankle rocker whereas the CFO

created
the smallest correction (significant compared with the PLS)
at the ankle. However, later in stance phase and in swing,
both PLS and Orteam

overcorrected the ankle dorsiflexion

whereas the CFO

increased the ankle dorsiflexion to a

(more) physiological angle. (Tables 1 and SII).
Because of the configuration of the selected AFOs, this
study aimed at evaluating the impact of the three different
orthoses (Orteam

, PLS, and CFO

) on push-off. All three

orthoses were expected to preserve the kinematics and
kinetics of this final phase of stance. As mentioned before,
however, numerous studies indicate that applying an AFO
improves the overall gait pattern but also reduces, at the
same time, ankle range of motion and power generation at
push-off.
1,36,8
This was confirmed in the present study
(Table SI). However, compared with the two other orthoses,
the CFO

enabled the greatest ankle range of motion during

push-off. (Fig. 2; Table SII) Furthermore, both the PLS and
the CFO

significantly increased the ankle plantarflexion

moment in push-off but only the CFO

created an almost
physiological moment. Combined with an improved ankle
velocity, the CFO

allowed a more physiological third ankle

rocker compared with the Orteam

or the PLS. In a recent

study by Wolf et al.,
17
similar results for third ankle rocker
were observed when a carbon spring orthosis was applied
for patients with myelomeningocele and poliomyelitis.
PROXIMAL PARAMETERS
The improved distal stability in orthoses facilitated range of
motion in more proximal joints which was apparent through a
more fluent knee movement in swing as knee velocity
increased while the timing of peak knee flexion in swing and
maximal knee flexion in swing decreased. However, the latter
remained above normal ranges in all orthoses (Table SII). This
more fluent knee movement, combined with a greater ankle
dorsiflexion, enabled an improved foot clearance in swing.
Knee shock absorption improved as well in the three types
of orthosis, confirming previously reported findings of
Brunner et al.
5
(Table SII).
When Buckon et al.
1
compared HAFO, PLS, and SAFO, all
three orthoses were observed to decrease knee hyperexten-
sion by preventing ankle plantarflexion, with the HAFO being
the most effective. Although similar influences were observed
in this study, no significant effect could be demonstrated. Both
the PLS and the Orteam

were observed to create a more phys-

iological knee extension in stance but neither of both achieved
statistical significance. Surprisingly, the CFO

seemed to cre-
ate knee hyperextension in stance. Furthermore, all three
orthoses increased the knee flexion moment in stance (signifi-
cant for the CFO

; Fig. 3; Table SII). These results are unex-

pected as the CFO

, Orteam

, and PLS were designed to

reduce the pathological plantarflexion-knee extension
moment. A possible explanation might be found in the
increased step length observed in all orthoses which shifts the
ground reaction force further anterior to the lower limb, thus
increasing the knee flexion moment. On the other hand, all
orthoses might have needed a more pronounced tuning,
enabling a greater influence on the knee flexion moment.
At the hip, greater ranges of motion were observed through
the use of orthoses (Table SI). Combined with an increased
66 Developmental Medicine & Child Neurology 2008, 50: 6367
Figure 2: Median and interquartile range of ankle range of
motion during push-off for the three different orthoses
(**p<0.01). CFO, Dual Carbon Fibre Spring AFO

.
Figure 3: Median and interquartile range of knee flexion
moment in stance for the three different orthoses
(**p<0.01). CFO, Dual Carbon Fibre Spring AFO

.
Orteam CFO Leafspring
Orteam CFO
Leafspring
48
44
40
36
32
28
24
20
16
12
8
4
0
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
**
**
**
**
Barefoot
Orthosis
Barefoot
Orthosis
step length, this resulted in higher moments around the hip
(only significant for flexion moment in the PLS and CFO

) and
a later timing in the gait cycle of zero hip moment for the CFO

,
compared with a barefoot condition (Table SII). Furthermore,
statistical analysis showed that the CFO

enabled a significantly
higher correction of the maximal hip flexion moment in stance
compared with the Orteam

(Table I).
These findings all indicate a substantial flexibility of the CFO

which allowed a greater range of motion in second rocker.

Conclusion
In general, all three orthoses enabled an improved gait pattern
with the greatest push-off observed in the CFO

while only the

PLS normalized the first ankle rocker. Although knee kinemat-
ics and kinetics did not fully improve as expected in the CFO

,
its flexibility was reflected in more physiological hip and spa-
tial parameters.
Accepted for publication 4th September 2007.
Acknowledgements
We thank Jozef Nijs and the multidisciplinary team of the Pellenberg
Clinical Motion Analysis Laboratory for their assistance and support,
and all the children for their enthusiastic participation. LVG is
funded by the Research Foundation Flanders.
Supplementary material
The following supplementary material is available for this article online:
Table SI: Mean and standard deviation for the gait parameters of the
total group of children with CP walking barefoot and with orthoses.
Table SII: Median and interquartile range for the gait parameters of
the three walking conditions.
This material is available as part of the online article from
http://www.blackwell-synergy.com/doi/abs/10.111/j.1469-
8749.2007.02014.x (this will link you to the article abstract)
Please note: Blackwell Publishing is not responsible for the content or
functionality of any supplementary materials supplied by the authors.
Any queries (other than missing material) should be directed to the
corresponding author of the article.
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Effect of Dynamic Orthoses on Hemiplegic Gait Leen Van Gestel et al. 67
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